NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Correct Answer: B
Rationale: Exudate (moist, active drainage) is a clinical sign of wound infection. Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. Edema (swelling) is a clinical sign of wound infection. Erythema (redness) is a clinical sign of wound infection.
Question 2 of 5
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
Correct Answer: B
Rationale: Urinary output of 20 mL/hour is below the expected minimum of 30 mL/hour, indicating potential renal compromise or hypoperfusion, common risks after aneurysm repair. This requires further investigation. The other findings are within acceptable post-operative ranges.
Question 3 of 5
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, 'Nobody in here seems to really care about the clients. I thought nurses cared about people!' The client is exhibiting the ego defense mechanism:
Correct Answer: C
Rationale: Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.
Question 4 of 5
The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following?
Correct Answer: B
Rationale: Exercise lowers blood sugar, so a snack may be needed to maintain appropriate glucose levels. The other options are incorrect as they increase the risk of hypoglycemia or are factually inaccurate.
Question 5 of 5
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, 'My doctor is in love with me and wants to marry me.' This client is using which of the following defense mechanisms?
Correct Answer: B
Rationale: Displacement involves transferring feelings to a more acceptable object. Projection involves attributing one's thoughts or feelings to another person. Reaction formation involves transforming an unacceptable impulse into the opposite behavior. Suppression involves the intentional exclusion of unpleasant thoughts or experiences.